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OW R�COMPENSATION DECLARATION 76A663 10i81 ppp��CATION FOR ELECTRICAL P�RM1T �
I hereby.affirm thot I have a certificote of consem to self CE-amG
insure,or a cer�ifica�e of Workers'Campensa�ion Insurance, COUNTY OF LOS ANGELES BUILDING AND SAFETY
'or a cerfified copy thereof(Sec.3800,Lab.C.)
P❑olicy No.S�'25859571ComPa�y IhA FOR APPIICANT l0 FlLL IN JOB
Certified mpy is hereby furnished. New Residenliol Bldgs.&Pools EACH NO. FEE /+DDRE
� Cerlified copy is filed with rhe county building inspec- 1 B 2-Family,Sq.R. SSG3 ; — S IOCAL Y
tion depor7menf. Multi-family Sq.Ft. — NEAREST
CRO55 57.
8I20/86 ����� MC�2 Electri RBsidential Swimming Pools OWNER pR
Dote Applicant FIRMNAME The Anden Gr .
CERTIFICA7E OF EXEMPTION FROM WORKERS' Ovtlets:Rec._,_light`Sw._ �MAII
COMPENSATION INSURANCE Fir5120 ADORE55 1074 Park View Dr.
(Thi��oction n��d not ba aomplefed if tM work inrolwd by Total No. qdd���o�o� CIN Covina, Cd. Tei,r.�967-9541
fhe psrmit is for one hundr�d dolla�c(5100}or leu.) PtaN CHECK
I certify ihar in the performance of the work for which ihis APPLICANT �
permit is issued,I shall no�employ any person in any manner
so as fo bemme subjed 1a tbe Workers'Compensalion Lows. Lighling Fix�ures Firsf 20 ADDRESS
� � Total No. Additional
CITY Tel.No.
1�'� Applicant Fixed Appliantes Not Over 1 HP PERMIT
� ,ICE 70 APPLICANT: If, after making this Certificate of APPLICANT ��'j'�� 1+[ p.2 Elect ic
Ezemption, you should become subje0 to the Workers' Range_Heater.^D.W.�
Compensotion provisions of Ihe La6or Code,you must forlh- Oven �Dryar —W.M., ADDRESS
wirh wmply witb.such provisions or this-permit shall 6e Top _.FAU �W.H.—
deemed revoked. CIrY 1708 iel.IVo591-6461
LICENSED CONTRACTORS DECLARATION Hood _Fon _O�har_
LICENSE OR
I here6y affirm�hot I om licensed under provisions of Chapter 9 Disp. _..Room Air Cond. — REG.NUMBER 490083 Clas�.-1�
(cammencing with Sedion 700D)of�ivision 3 af the Business pISTRICT NO. PROCESSED BY d'
and Professions Code,and my iicense is in full force and effeci. Power Appora�us 8 large Appliances !� 0
Size 8 Type HP,ICW,KVA,or KVAR� � C)
License Number GO�_(1R4 Lic.Class C-1 fl. Up to 1 Ind. FINAL �
Electrical $�Z���6 Over I ro 10 Incl. DATE � b �r VA ATION F��—
Controctor ��e Over 10 fo SO Ind. FINAI W
❑ I om exemp�under Sec. Over 50 l0 100 Inc. BV �
B.&P.C.for�his reason �Ve��� z
Daie: Services,Swbd.,MCC 8 Panelboa�ds ►
0-200 Amp.Under 600 V
Signature 201-7000 Amp.Under 500 V �
❑ Over 1000 Amp.or Ovar 6pp V
Exemption for Reg.Moint.Elect.
�
� !"`` SINGLE FAMILY Temp.Powar Pole&Appurtenances ._�3 8.O F
HOME OWNER-BUILDER DECLARATION Sign with One Bronth Circuit
I hereby affirm�hat 1 om ezempt from rhe Conhoctor's License Additional Sign Branch Circuils �:;e •w • l'�
Law far the following reason(Section 703I.5, Business and
Professions Code): � e b'�3�2
❑ I,as owner of�he property,will do the work and Ihe Misc.Conduits 2,Condudors � �
structore is no�in�ended or offered for sole ($action Other{See.Comple�e Fee Schedule)_. :"� '"��.C G c�
7044,Business and Professions Code). � 0 8.2 0-8 6
CONSTRUCTION LENDING AGENCY
�hereby affirm tha�fhere is a construttion lending agency for
the performance of the work for which fhis permit is issued PERMIT FEE �S�b-Totol� 6�.50 �
(Sec.3047,Civ.C.).
PLAN CHECKING FEE
Lender's Nome
� PERMIi ISSUING FEE 1 .S �
Lender's Address
I certify ihal I have read Ihis application ond state thot Ihe TOTAL FEE � 73.p
above information is correct.I agree to comply with all County
ordinances and Stote laws regulating Electriml wiring,ond
hereby au�horire represeNatives of this County 10 enter upon
�fie 6ove-mentioned property for inspecrion porposes. SEE REVERSE FOR EXPLANATORY LANGUAGE
1d(u����i� _$/2Q/86 .
Signoture of Permittee Dale
!��'� 1l� '�T ' � !i' � N:�� ' � _� ,w�1�
��Q4`JhlER-6UlLDER DQCifcRATI�IV
�ApPRt]VAlS, DAT: SIGNATI.)R: -
.. . .. ..., �- j TfMP.FflW.k�PD`.E'�....� �_.� .- . I her�by aifirm±haf I am exempt from the Gontra[�or's
. , , � � - —j- �� -- �- 4icense law£ar tha followine� raoso� ($action 709L5.
�U'V�)E�.^�S A�+JJ��s, I � �Usinvss and ProfeSslatts Codej�Any cily or�courtty whlch
�_._�L�.---._.�
RL7LJGN C�PJD'JIT � . requtres a permif ta mnstruct,olfer,imp ove;�,demoRsh,
�� �'or raFctr any rtructure,prior to Hs lisuancs,�afso rn-
� � WIRIPvG ���/x�r tt��(. pr.,�"' � qulres ihe ap�lltonf!or such permit io ftle a slgrted stata-
. --�i ��7�` ----"� ment lhaE he Is IFcensedpursuant to fhe provlslons of iha
, - - r�l���`` - . Cpnmectcri i.lcense Low(Chopter 9(carrrmeneing with
, . �..._.�..� �._�. . . :��.:-�,.._—'--'__--.- - .
Seci+on 7P00 0!Divfsion 3 oi the Buslness and Proiss�
. i�OltiE2 AI+�I�u��ZrP ( )
�---� � sions Code)or tHat he ls axempt ihe�efrom and�he ba:is
. �VT4!iTY CO.NOTlF!i� —� far 4he alfaged exemptian. Any violo}�an of Ssctton
�Ffh�m t � ' � � 7037.5 by any a�pllrnn}!er o permif subjxts the oppfr-
�� � .C..nfor a.�_�ror.f . � ccM to a ttvlf penaity of not more than fivo hvndred
�n3C)7ES , dailars($50�}.� -
u I,as nwner af th�s properiy will dc rhe work, .d
—_ ___.._ -�-� ___._._..,._.w�.. ___. +ha slru<rura is not intended or offared far sale.-
. � {Sec.9044,B:ssiness cndFrofclslons Code: The Contrac�
_ ' - r' '_ _ _ __ tor's llc�ense Law dous not app7y+o on owrter of propertp
, _ � , , - . who bWtds ar�lmproves �horean, ond wfio does such
.,�_�,_. ,__ ,�� _ wo�k htmseff provided}hci sutfi improvements are not
��- " ' � - � �o+ended or of£er�rllar iate.!I,however,the 6v11ding or
_ _,,,,,_ ____ lrcprovemenl Is so/d wlfh(n one ysar of completion,�Ihe
owner-6uflder wNf have fhe burd�n o(provtng thah M1e did
' �. . __„ ._ . , .n,of 6u1ld or Improve for ihQ,purpose of sale.)
�' ��� I.6"rsi,Qxompt underSacr��.•-..�-.. .
.____ .__- ---.__,—_.-....__ ..-----. 6 8 P.C.far this ranson
_—_ ._._.__��..�.._..._. ...-- ` Date —.�.. .
_. _ ...�._.__��_._..._._,�,_�_.._�_.a .
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